Credentialing vs. Privileging and CMS Requirements

In healthcare, credentialing and privileging are distinct but related processes essential for ensuring patient safety and quality care.

Key Differences between Credentialing and Privileging

Credentialing: Verifies a practitioner's qualifications, including licenses, certifications, education, training, and experience.

Privileging: Grants specific permissions for a practitioner to perform particular patient care services or procedures based on their demonstrated competence.

Privileging builds on credentialing—practitioners must be credentialed first before privileges are awarded.

CMS Requirements

The Centers for Medicare & Medicaid Services (CMS) sets Conditions of Participation (CoPs) that hospitals and other facilities must follow to participate in Medicare and Medicaid.

Key standards include:

Governing Body (§482.12): Must ensure privileges are based on character, competence, training, experience, and judgment—not solely on certifications or society memberships.

Medical Staff (§482.22): Bylaws must define criteria and procedures for granting privileges.

Note: A boring as it may be we advise all of our clients to review the §482 rules and regulations. 

Code of Federal Regulations (42 CFR Part 482): This part establishes the "Conditions of Participation for Hospitals" that must be met for a hospital to receive Medicare and Medicaid payments.

The hospital and medical group executive leadership know these rules and they are supposed to follow them.  Discipline may seem to a doctor to come out of the blue but the executives may think they are following these "CFR's".  On the other hand, if a doctor is under scrutiny and the hospital or medical group has not followed the CFR rules, that is a weakness that a good defense lawyer can exploit.

A 2004 CMS guidance emphasizes that:

Individual evaluation of each practitioner's qualifications and competencies.

Privileges must be specific and tailored—no assumptions based on category alone.  This rule is (in our experience) ignored more frequently than it is followed.  It has broad implications in peer review settings and in medical malpractice actions involving complex cases where a general privilege may be deemed inadequate to justify a more complex procedure.  (And yes, this arises most frequently in surgery cases.)

• Assessment factors: Current practice, training, outcomes, education, continuing education, certifications, licensure, and compliance.

Accrediting bodies (e.g., The Joint Commission, DNV-GL) must meet or exceed CMS standards through "deeming."

There is much more on this issue and it can be important in peer review, summary suspension and malpractice actions.

If you need a medical lawyer, call Daniel Horowitz at 925-283-1863.  We will discuss your case briefly to see if our expertise matches your needs.  If it does, we will set up an initial session with Daniel Horowitz personally to further explore your needs and your options.